Healthcare Provider Details

I. General information

NPI: 1003858416
Provider Name (Legal Business Name): HEFNER WEST MEDICAL CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 NW 63RD ST
OKLAHOMA CITY OK
73116-1545
US

IV. Provider business mailing address

4400 NW 63RD ST
OKLAHOMA CITY OK
73116-1545
US

V. Phone/Fax

Practice location:
  • Phone: 405-942-0090
  • Fax: 405-942-8055
Mailing address:
  • Phone: 405-942-0090
  • Fax: 405-942-8055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number11815
License Number StateOK

VIII. Authorized Official

Name: LABID SAM MUSALLAM
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 405-942-0090